Docs, EMT's - Drawing blood: Which way should the needle be oriented?

Factual Questions
1

I stumbled across this quite by accident, and it made me curious: is bevel-down a better way to draw blood (in most patients)? Myself, I’m an extraordinarily easy stick - most of my veins are large and visible. I’ve been burned by this several times, however. Sometimes the needle goes right through the back wall of the vein and leaves me with a nasty purple bruise at the site. Would this method help? And which method is taught to Docs, EMT’s, these days? If it’s still bevel-up, why?

Thanks for any input.

s/f

2

In Med Tech school, we were taught to stick with the bevel up. I’m not sure why, but it may have something to do with guiding the needle in. Going through the back wall of the vein is often done by those going in a too steep an angle.

Vlad/Igor, MT(ASCP).

3

There is some talk of rotating bevel down after the skin is pierced. Mostly for thin skin granny types.
Then there is also talk of slight curves being made in the catheter for junky veins.
But I am retired now and don’t need to keep updated on all the new tricks.

4

Blowing a stick like you describe above is just as easy bevel up or down a needle is very very sharp and the edges of the bevel are sharp as well. Everything I ever saw was bevel up, but as mentioned above, its been a few years for me too.

5

All current teaching & training is still bevel up. Also, if you inserted the needle bevel down, it would cause the skin to bunch up as the needle is inserted. This tends to be painful, often more so than the actual needle stick. It would also make the stick more difficult.

St. Urho
Paramedic

6

The reason for the bevel up approach is for ease of flow. Because the needle enters at an angle, if the bevel were down it sucks up the back wall of the vein, restricting flow. This from my old dialysis manual, there could be new thoughts on the subject. Also, pulling blood around the tip instead of straight in, causes turbulance, which can damage cells and effect lab results.

BTW, nurses draw blood too.

7

Yeah, I’ve only ever been taught to do it bevel up. Also, if a phlebotomist is continually going all the way through patients’ veins leaving bruises, they have either poor technique or judgement, IMHO.

-Lab bitch

8

Assuming you’re not playing darts and trying to stick the needle at 90 degrees to the skin, bevel up presents the sharpest possible approach into the skin. Bevel down will be somewhat like trying to plow your way thrugh the skin. If your angle of attack is low enough, you could end up with the bevel itself skimming along the skin until the tip of the needle gets a bite and goes in.

9

I’ve given a lot of blood over the years to the Red Cross, and have had folks with a wide range of skills stick me with needles. Some were borderline-incompetent and it hurt like hell. Am I the only one who winced as he read this thread?

10

That’s about what I was going to say.

My Med Tech training was bevel-up, both in the classroom theoretical stuff, and SOP in the three hospitals where I spent my internships.

Antigen, MT(ASCP)

11

First, my reaction to this thread (and others at AllNurses.com and Indeed.com) … simply stated I am horrified! Although this problem has many aspects including preparations, procedures and “being confident”, when performing a venipuncture, the needle orientation is the single most important aspect governing a successful flash and draw. All the other advise is great but if you can’t see that keeping the plane of the bevel parallel with the plane of the vein is of utmost importance, the whole thing is a crap shoot! I read about “good days and bad days” and I it’s no wonder because with the bevel up you will always be running the greater risk of blowing through the vein to the other side!

Even if “bevel up” can be a little less painful with a quicker penetration “bevel down” offers a much better opportunity to keep from blowing one vein after another with bad technique!

The studies that were performed by nurses and others who were most familiar with the bevel up approach had better success with that procedure because it was the one that they were most familiar with.

I’ve read enough articles on the subject to see that the biggest obstacles to making the change to “bevel down” are that “It’s the way we’ve always done it” and “I’m not going to change the way I’ve been doing it for so long”. Tradition and medical dogma stand in the way of a better technique! For those lacking the common sense to see the obvious they will be bound by their academia and supervisors. And they will continue with their “crap shoot” and their patients will continue to suffer the consequences.

It comes down to pure mechanics, BEVEL DOWN for BETTER FLASH and DRAW!

12

I was taught bevel up, and the thought never crossed my mind to try a different orientation.

13

Well, I’ve always gone bevel up, that’s what I was taught and haven’t had a reason to question it. But I’m always on the look out to improve my pt care, so if you have some credible references to support bevel down, I’d be interested in seeing them.

14

Look, there are people having their 15th blood test of the day for whom the orientation of the bevel may make all the difference between a successful stick, and blowing through their last usable vein.

For the average Joe, getting a blood test once in a blue moon, the orientation of the bevel is fairly irrelevant- any competent person should get blood first time, no matter how crap the veins, because you pick the BEST spot and you’re going into virgin territory, using the smallest needle you think you can get away with.

Going through the vein with a venflon/ cannula is just about understandable, popping a vein while taking blood using a small gauge needle- less so.

Bear in mind I have worked in Paeds, where you only got 2 chances to get blood or a line in before you have to call for the Reg (senior resident). You soon learn to do it right to avoid that scenario, and if you can get blood from a chubby, struggling 3 year old first time, you can get blood from ANYONE.

I’d argue that skill and practice matter more than anything.

Case in point-
I have arms like Madonna’s, you could throw venflons into me from across the room.
I’ve volunteered for the medical students to practice taking blood and putting in venflons before they are let loose on patients and so far only one of them has failed to get first time with me.
I’ve taken my own blood one handed (yes I got it first time, and no, it didn’t hurt more than usual).
When I had my c-section the anaesthetist put in a 14G venflon, just to see if he could.*
In short, I have very good veins.

And yet, a nurse still managed to stick a 21G needle in my median nerve while trying to take my blood. Not an experience I would recommend, and why I’m now one of those people who points to the juicy veins, just in case the next person who takes my blood should have a similar level of “skill”.
*He used local, he did ask first, and he’s a mate of mine, so I didn’t mind, but I do have a scar to show for it.

15

I’m now seriously tempted to try a comparison bevel up/bevel down study with some 23G needles, 2ml syringes and my own foot (so I can use both hands).

I won’t, because I don’t have a sharps bin at home, but I’m still tempted.

Anyone else?

16

When I go to donate blood, in the cantina afterwards, they have those juice drinks that come in a foil pouch, that you open by poking the straw through the seal at the top. Put the straw in so it’s bevel-out, and it’s easy to poke through. Put the straw so it’s bevel-in, and it’s almost impossible, and when you do get it in, you usually end up with juice splattered all over you.

17

I believe it would revolutionize phlebotomy if the needle was oriented bevel-up for the initial penetration and then SIMPLY ROTATE to the bevel-down position as soon as it enters the vein.

This technique allows the phlebotomist to give the appearance of following the academic policies mandated. Then instead of probing and fishing with excessive movement simply TWIST the collection tube 180 degrees so that the bevel is parallel with the vein.

I’ll bet this happens accidentally all the time but unbeknownst to the phlebotomist because we loose the visual orientation of the bevel immediately after penetration.

We chalk it up to “having an easy stick”.

Please click on the link up top in Sangfroid’s original post where it says, “I stumbled across THIS quite by accident”. LOOK at the diagram of the two needles inside the vein (lumen). If a light comes on in your head you will be well on your way to an amazing reputation with your patients for hitting veins no one else can!

Here is the link to the blogspot and the DIAGRAM:
=> Musings of a Dinosaur: Bevel Down

Bon courage!
fredmeister

18

Not me. I can handle blood so long as it’s not my own…

19

Not a medical professional, but I’m a habitual donor of blood and platelets (just did my 102nd donation). All the techs seem to go bevel up.

There’s a problem with that drawing, though. It has both needles entering the skin at about a 45-degree angle, which no one ever does. The sticks are at a very low angle, such that the needle and vein are concentric, or as close as they possibly can be to concentric. Using a low angle, it seems to me, makes the final orientation of the bevel less important, as well as reducing the chance of going through the far side of the vein.

20

I learned bevel up. No reason was given to us, and I never thought to question it. Just seemed to make sense given that you were leading with the sharpest part of the needle. Now I’m a little curious as to which way is more evidence based though.

3rd year med student.